CMS proposes ‘major’ changes to oxygen benefit

WASHINGTON – CMS’s proposed national coverage determination for home oxygen therapy – its first revision since 1993 – makes “groundbreaking” changes, including expanding access for acute conditions and removing the CMN requirement. 

Industry stakeholders say the agency is proposing the changes largely as a result of the COVID-19 pandemic, which significantly increased the number of people needing oxygen and exposed issues with the current NCD. 

“We haven’t seen something this major happen in a long time,” said Kim Brummett, vice president of regulatory affairs for AAHomecare. 

CMS is accepting comments on the proposed NCD until Aug. 1. Once the agency publishes a final NCD, it will become effective and the medical directors at the DME MACs will get to work developing policy articles and local coverage determinations, a process that could take six months. 

‘Ability to breathe’ 

Expanding oxygen access to patients with acute conditions while removing the “chronic stable state” requirement, facilitates a comprehensive approach to the benefit, says Andrea Stark, a reimbursement consultant for MiraVista. 

“There’s always been a disconnect between patients who have a need for the therapy and whether or not insurance would reimburse for it,” she said. “With this NCD, the connection between need and reimbursement is much more aligned.” 

Coverage would be more about “the ability to breathe,” says Brummett, with CMS proposing initial coverage of 90 days or less for situations unrelated to hypoxemia, with renewed coverage available within 60-90 days for continued need. 

“That’s what has happened with COVID-19 in a lot of cases,” she said. “We have patients on service who no longer have COVID, but they still rely on oxygen to breathe.” 

‘Processing tool’ 

Dropping the CMN requirement would streamline the claims process for providers, says Ronda Buhrmester, senior director of payer relations and reimbursement for VGM & Associates, because the CMN is a “duplication” of the medical record – they both must show medical necessity. The agency is also reducing the possibility of denials. 

“Providers would no longer be chasing down the physician for a signature,” she said. “They’d be able to put a claim in based on the standard written order and the medical record.” 

The public health emergency, during which there have been a number of waivers in place for respiratory therapy, has shown CMS that the CMN is basically a “claims processing tool,” Buhrmester says. 

“Their technology has advanced,” she said. “They don’t need it anymore because the details within the medical record accomplish the same goal.” 

‘Gray areas’ 

There is uncertainty, however, around what CMS will use to monitor compliance if there is no CMN, Stark says. 

“This is something we really need to think about,” she said. “Are they going to rely on the KX modifier? Are they going to impose new criteria? The MACs have many tools in their toolbox but, because the proposed NCD opens up the benefit to more patients, the volume of claims could limit which tools can be effective.” 

It’s important to remember, Stark says, that the proposed NCD, while “groundbreaking,” isn’t “carte blanche set it and forget it.” 

“The supplier still has to know what’s in those medical records,” she said. “As you introduce acute patients and those with short-term needs, there’s increased burden to monitor them and ensure their equipment is being used. When does the patient get better? When do they go from being acute to chronic? All of these are gray areas.”